Types of treatment for myeloma

Chemotherapy, steroids and biological therapy are the main treatments for myeloma. Radiotherapy is also used to help control pain. You may also have bisphosphonates to help prevent bone damage and relieve pain. If you are fit enough, your specialist may suggest intensive treatment using high dose chemotherapy with bone marrow or stem cell transplant.

Your doctor may suggest a treatment called plasmapheresis if the level of abnormal immunoglobulin protein is too high in your blood. Too much protein in the blood can make it too thick and plasmapheresis will take out the excess protein.

The main aim of your treatment is to try to get the myeloma under control. When there is no sign of active disease in your body, the myeloma is said to be in remission.

Which treatments are right for you will depend on

• How far your myeloma has developed (the stage)
• Your symptoms
• The results of your blood and bone marrow tests
• Your general health and levels of fitness
• Your personal preferences

Doctors also call myeloma without symptoms asymptomatic, or 'smouldering' myeloma. If you have no symptoms, your doctor may suggest keeping a close eye on you, rather than treating you straight away. This is because, over some years, there may be a limit to the amount of treatment that will help. If the disease is not causing you problems, your doctor may think it better to keep treatment in reserve. This is a decision that your doctor will have to discuss with you, bearing in mind your particular circumstances and test results. Your doctor may call this approach to managing your disease 'watch and wait' because he or she will be keeping a close watch on your health.  There is no strong evidence to show that treating asymptomatic myeloma improves survival.

A 2003 Cochrane review found that treatment may slow down the development of the disease, although there wasn't enough evidence to show whether it helped people to live for longer. You can read this review of early myeloma treatment in the Cochrane Library. It was written for researchers and specialists so is not in plain English.

Bisphosphonates are drugs that doctors use to help prevent bone damage in myeloma. They are used to treat high levels of blood calcium. At the moment there is not enough evidence to say if bisphosphonates help people who have myeloma that is not causing symptoms.

If you have myeloma that is causing symptoms, you are most likely to have chemotherapy. Which drugs you have will depend on how the myeloma is affecting you and on your general health. For example, if you have kidney damage, this will affect the choice of chemotherapy drugs that your doctor can use. You will probably have steroids as part of your chemotherapy regime. With experience and through research, doctors have found that the chemotherapy works better if you have steroids at the same time.  Doctors are increasingly using biological therapies such as thalidomide or bortezomib (Velcade) alongside chemotherapy and steroids.

Once your disease is under control (in remission), your doctor may suggest a course of biological therapy to try to keep it under control for longer. This is called maintenance therapy. This is usually thalidomide.

If you are under 65 and are fit enough, your doctor may suggest further intensive treatment with high dose chemotherapy and stem cell transfusion. This is often called a stem cell transplant. Occasionally bone marrow is used. This is usually your own stem cells or bone marrow, rather than those of another person. 

Older people and those unable to have intensive treatment with a stem cell transplant may have thalidomide with the chemotherapy cyclophosphamide or melphalan, and a steroid.  If you are unable to have thalidomide you may have bortezomib (Velcade) in combination with melphalan and prednisolone.

If you have signs of bone damage or are having bone pain, you will probably have radiotherapy to the area that is causing trouble. If the myeloma is affecting your bones in many areas, you may have radiotherapy to a wider area. 

Bisphosphonates are drugs that have traditionally been used to treat symptoms of several different types of cancer affecting the bones. They are still used for symptoms and are particularly good for lowering levels of calcium in your blood. There is now evidence that they may delay the development of bone damage and so they are sometimes used as active treatment, rather than just to control symptoms. A review of all the evidence on this, by the Cochrane Collaboration found that bisphosphonates can lower the risk of fractures of the spine and reduce bone pain. Guidelines written by the British Committee for Standards in Haematology (2010) recommend that all myeloma patients who have symptoms should have bisphosphonates.

Your doctor may call this relapsed myeloma. If your myeloma returns your doctor may suggest treatment with the biological therapy bortezomib  (Velcade). If bortezomib is not suitable for you, your doctor may suggest another treatment. This may be a different combination of chemotherapy drugs with or without a biological treatment such as thalidomide or lenalidomide (Revlimid). The National Institute for Health and Clinical Excellence (NICE) said in 2009 that lenalidomide with dexamethasone should be available to people with myeloma who have already had at least 2 different treatments.

Even if it is not possible to get your myeloma into remission, you can have treatment to help control the symptoms it causes. This may be with mild chemotherapy. Or you may have radiotherapy to any trouble spots in your bones. Bisphosphonates can also be used to try to prevent and treat bone damage. And to reduce the levels of calcium in your blood, if this is too high. There is information in this section of CancerHelp UK about controlling myeloma symptoms.